膝关节周围恶性骨肿瘤的保肢治疗(附48例随访报告)

Limb salvage for malignant bone tumors around the knee joint:a report of 48 cases

目的总结膝关节周围恶性骨肿瘤的保肢治疗经验。方法回顾分析1999年2月～2007年2月48例接受保肢治疗的膝关节周围恶性骨肿瘤患者的临床资料。男30例,女18例。平均年龄27.3岁(11～67岁)。病理证实:高恶性肿瘤32例(A组),包括骨肉瘤23例,恶性纤维组织细胞瘤5例,尤文肉瘤2例,恶性淋巴瘤2例;低度恶性肿瘤16例(B组),包括侵袭性骨母细胞瘤1例,骨巨细胞瘤15例。手术方式包括:瘤段切除假体置换术或灭活再植术、异体骨移植术、异体骨复合假体移植术、病灶刮除充填术保肢。A组术前、术后给予化疗。保留肢体功能按Enneking肌肉骨骼肿瘤外科治疗重建后功能评估标准评估。结果平均随访3.2年(0.5～8年)。A组中因局部肿瘤复发、感染等并发症截肢11例(34.4%),死亡13例,存活19例,3年存活率59.3%(19/32)。B组中因局部肿瘤复发和感染截肢2例(12.5%,2/16),死亡1例。肢体功能优良率A组71%,B组81%。结论膝关节周围恶性骨肿瘤保肢应掌握个体化原则,假体置换术及异体骨复合假体移植术保肢功能最佳,高恶性肿瘤患者若无法承受强力的辅助化疗则不宜行保肢术。

Objective To summarize the experience of limb salvage in malignant bone tumors around the knee. Methods The data of 48 patients （30 men and 18 women） were retrospectively analyzed. All of them had malignant tumors around the knee, and underwent limb salvage between February 1999 and February 2007. They aged from 11 to 67 years old （average age is 27.3 years）. All patients were divided into 2 groups according to the grade of pathology, as high grade （group A） involving 32 patients, and low grade （group B） inolving 16. The diagnosis of group A was osteosarcoma in 23 patients, malignant fibrous histiocytoma in 5, Ewing＇s sarcoma in 2, and malignant lymphoma in 2; the diagnosis of group B was invasive osteoblastoma in 1 patient, and giant cell tumor in 15. The methods included prosthetic replacement, devitalized original tumor-bearing bone, allograft bone, allograft combined with joint replacement, and composite padding. The patients of group A were given neo-adjuvant chemotherapy and postoperative adjuvant chemotherapy. Salvaged limb function was evaluated by Enneking＇s musculoskeletal tumor surgery for the reconstruction of postoperative functional evaluation criteria. Results The average follow-up lasted 3.2 years （ranged from 05. to 8 years）. In group A, 11 （34.4%） patients underwent amputation because of recurrence or infection; 13 patients died; 19 survived. The survival rate 3 years after surgery was 59.3%. In gruop B, 2 patients underwent amputaiton because of recurrence or infection; 1 patient died. The limb function was assessed by Enneking system, and the excellent rates were 71% （group A） and 81% （group B）. Conclusions Prosthetic replacement and allograft combined with joint replacement are better options for patients with malignant tumors around the knee, and the preoperative and postoperative chemotherapy are the key factor to achieve an ideal limb salvage for osteogenic malignant tumors.